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Introduction The 11th revision of the WHO International Classification of Diseases (ICD-11) has identified Complex PTSD (CPTSD) as a new condition. Aim To explore whether the new diagnosis of CPTSD (ICD11) is relevant to women who have experienced perinatal bereavement and to advance knowledge about the acceptability, feasibility and perceived impact of delivering an innovative flexible Compassionate Focused Therapy (CFT) informed treatment package to alleviate symptoms of this condition. Methods A mixed methods study using survey and interviews was conducted. Participants first completed the International Trauma Questionnaire (ITQ) to assess if they met the criteria for PTSD or CPTSD (n=72), and subsequent semi-structured interviews (n=12) identified participants’ views about different treatment approaches. Participants A convenience sample of women who had experienced perinatal bereavement were recruited from one geographical region in Scotland. Data collection Information was gathered about trauma experiences related to perinatal bereavement; participants’ levels of PTSD or CPTSD using the ITQ; and views regarding the features of treatment options. In-depth interviews with women (n=12) and a focus group with staff (n=5) were also conducted. Findings Of 74 participants (n=74) who fully completed the ITQ, 10.8% (n=8) met the criteria for PTSD and 29.7% (n=22) for CPTSD, equating to a total of 40.5% of participants experiencing traumatic stress. Results suggest that CPTSD is a more common condition than PTSD in people with perinatal bereavement, with qualitative data suggesting that CFT and EMDR can be useful and acceptable interventions for this population group. Conclusion A feasibility study is recommended next to evaluate acceptability of trial processes in preparation for a definitive randomised controlled trial of a new flexible CFT informed treatment package to address PTSD and CPTSD in people with perinatal bereavement. Recommendations for practice Routine assessment of ICD-11 CPTSD is recommended in this population group.

Background Mental health problems are common in the working population and represent a growing concern internationally, with potential impacts on workers, organisations, workplace health and compensation authorities, labour markets and social policies. Workplace interventions that create workplaces supportive of mental health, promote mental health awareness, destigmatise mental illness and support those with mental disorders are likely to improve health and economical outcomes for employees and organisations. Identifying factors associated with successful implementation of these interventions can improve intervention quality and evaluation, and facilitate the uptake and expansion. Therefore, we aim to review research reporting on the implementation of mental health promotion interventions delivered in workplace settings, in order to increase understanding of factors influencing successful delivery. Methods and analysis A scoping review will be conducted incorporating a stepwise methodology to identify relevant literature reviews, primary research and grey literature. This review is registered with Research Registry (reviewregistry897). One reviewer will conduct the search to identify English language studies in the following electronic databases from 2008 through to July 1, 2020: Scopus, PROSPERO, Health Technology Assessments, PubMed, Campbell Collaboration, Joanna Briggs Library, PsycINFO, Web of Science Core Collection, CINAHL and Institute of Occupational Safety and Health (IOSH). Reference searching, Google Scholar, Grey Matters, IOSH and expert contacts will be used to identify grey literature. Two reviewers will screen title and abstracts, aiming for 95% agreement, and then independently screen full texts for inclusion. Two reviewers will assess methodological quality of included studies using the Mixed Methods Appraisal Tool and extract and synthesize data in line with the RE-AIM framework, Nielson and Randall’s model of organisational-level interventions and Moore’s sustainability criteria, if the data allows. We will recruit and consult with international experts in the field to ensure engagement, reach and relevance of the main findings. Discussion This will be the first systematic scoping review to identify and synthesise evidence of barriers and facilitators to implementing mental health promotion interventions in workplace settings. Our results will inform future evaluation studies and randomised controlled trials and highlight gaps in the evidence base. Systematic review registration Research Registry (reviewregistry897)

AIMS: To focus asthma care on those patients most in need whilst providing annual audit data. METHODS: An observational questionnaire study. Patients on the asthma register received a postal invitation to the asthma clinic plus a questionnaire which enquired about both symptoms and the process of care. Medical records were searched for data on non-responders. RESULTS: Of the 1241 people sent the invitation and questionnaire 682 (57%) returned it and 99 attended the clinic. Follow-up of responders with high morbidity resulted in a further 32 people attending. The 99 attenders had a higher morbidity than non-attenders on the criteria of a course of oral steroids in the last six months(15% v 29%)and a mean symptom score of 3 or more ( 12% v 31%). CONCLUSIONS: Whilst the process did focus care on those in need, and resulted in a manageable number of people attending the asthma clinic, many individuals with high morbidity or risk factors did not attend.

Background Chlamydia trachomatis (C. trachomatis) is the most common bacterial sexually transmitted infection in the UK. Recent studies suggest that in addition to the genital tract, C. trachomatis is found in the throat and rectum, suggesting the number of infections is under-reported. There is an urgent need to study the impact of extending diagnosis to include extra-genital samples; however, there is a lack of evidence on the acceptability of asking young women to provide these samples. Method A mixed methods single group feasibility study explored the acceptability of combined genital and extra-genital testing in young women aged 16–25 years consecutively attending a sexual health centre in Edinburgh, Scotland. Young women were asked to complete a self- administered anonymous questionnaire whether they would be willing to give self-taken throat and ano-rectal samples. Interviews with women (n = 20) willing to self-sample were conducted before and after self-sampling, and these explored the underlying reasons behind their decision, and feelings about the tests. Results Of 500 women recruited to the study, 422 (84.4%) women provided sufficient data for analysis. From completed questionnaires, 86.3% of respondents reported willingness to self-sample from the throat. Willingness of ano-rectal self-sampling was lower (59.1%), particularly in women under 20 (

To identify factors which may help or hinder decision-making ability in people with psychosis, we did a systematic review and meta-analysis of their performance on the Iowa and Cambridge Gambling Tasks. Analysis of 47 samples found they had moderately poorer performance than healthy individuals (N= 4264,g= −0.57, 95% confidence interval (CI) −0.66 to −0.48). Few studies (k= 8) used non-psychotic clinical comparator groups, although very low-quality evidence (k= 3) found people with bipolar disorder may perform better. Negative symptoms (k= 13,N= 648,r= −0.17, 95% CI −0.26 to −0.07) and lower IQ (k= 11,N= 525,r= 0.20, 95% CI 0.29–0.10), but not positive symptoms (k= 10,N= 512,r= −0.01, 95% CI −0.11 to 0.08), each had small-moderate associations with poorer decision-making. Lower quality evidence suggested general symptoms, working memory, social functioning, awareness of emotional responses to information, and attentional bias towards gain are associated with decision-making, but not education, executive functioning or overall symptoms. Meta-regression suggested an inverse association between decision-making and depression severity (k= 6,Q= 6.41,R2100%,p= 0.01). Those taking first-generation (k= 6,N= 305,g= −0.17, 95% CI −0.40 to 0.06,p= 0.147) or low-dose antipsychotics (k= 5,N= 442,g= −0.19, 95% CI −0.44 to 0.06,p= 0.139) had unimpaired decision-making. Although meta-regression found no linear association between dose and performance, non-reporting of the dose was common and associated with larger impairments (k= 46,Q= 4.71,R214%,p= 0.03). Those supporting people with psychosis to make decisions, including treatment decisions, should consider the potential effect of these factors. Interventionist-causal trials are required to test whether reducing antipsychotic dose and treating anxiety and depression can improve decision-making in this group.

Faecal Sludge Management (FSM) is achieving traction in developing countries as a technical solution for the safe management (collection, transportation and in some cases treatment and end-use/safe disposal) of Faecal Sludge (FS) captured by onsite systems. Whilst some approaches do exist the overall availability of tools, data and practical examples to support decision makers in the implementation of FSM services on the ground is limited. This study aims to address some of these sector limitations by presenting a long-term costing methodology that was developed for two informal settlements in Lusaka, The Republic of Zambia. The approach compares the costs associated with a number of feasible fixed infrastructure and transportation technology scenarios over a 25 year design period. Within the analysis a spatio-topological tool was utilised to model proposed FSM networks and allowed the path of least-time transportation to be identified. This was then used to calculate Net Present Value and Average Incremental Cost, for seven different FSM scenarios, over a 25 year design life. The results of the study show that FSM could provide an affordable solution for the provision of sanitation services to Lusaka's poorest communities. The research conducted aims to support planners in Lusaka but also presents a number of methodologies that could be beneficial to the wider sanitation sector.

Sanitation service provision in fast growing peri-urban areas of developing countries cannot be achieved unless socially bound complexities are explored and diagnosed properly. Using primary data collected through household questionnaires and semi-structured interviews from three selected peri-urban communities in Lusaka, the Republic of Zambia, we analysed the influence of social dynamics on household sanitation provision. The study showed that whilst the socio-economic, perception, spatial proximity and social network factors explored had very little statistical impact on the current sanitation situation at the household level, in analysing the effect of these factors, novel insights into dynamics which may hinder progress towards improved sanitation access could be made. The study concludes that in Lusaka, successful interventions and improved access to sanitation will not be possible unless there is the presence of and access to strong social networks, in particular trust, cooperation and lines of communication, between and within the household and community levels. The need to directly engage with politicians so that their influence and power can be used to improve rather than hinder access to sanitation provision in these PUAs was also shown to be vital.

Objectives The effectiveness of psychological therapies for those receiving acute adult mental health inpatient care remains unclear, partly because of the difficulty in conducting randomized controlled trials (RCTs) in this setting. The aim of this meta-analysis was to synthesize evidence from all controlled trials of psychological therapy carried out with this group, to estimate its effects on a number of important outcomes and examine whether the presence of randomization and rater blinding moderated these estimates. Method A systematic review and meta-analysis of all controlled trials of psychological therapy delivered in acute inpatient settings was conducted, with a focus on psychotic symptoms, readmissions or emotional distress (anxiety and depression). Studies were identified through ASSIA, EMBASE, CINAHL, Cochrane, MEDLINE, and PsycINFO using a combination of the key terms 'inpatient', 'psychological therapy', and 'acute'. No restriction was placed on diagnosis. The moderating effect of the use of assessor-blind RCT methodology was examined via subgroup and sensitivity analyses. Results Overall, psychological therapy was associated with small-to-moderate improvements in psychotic symptoms at end of therapy but the effect was smaller and not significant at follow-up. Psychological therapy was also associated with reduced readmissions, depression, and anxiety. The use of single-blind randomized controlled trial methodology was associated with significantly reduced benefits on psychotic symptoms and was also associated with reduced benefits on readmission and depression; however, these reductions were not statistically significant. Conclusions The provision of psychological therapy to acute psychiatric inpatients is associated with improvements; however, the use of single-blind RCT methodology was associated with reduced therapy-attributable improvements. Whether this is a consequence of increased internal validity or reduced external validity is unclear. Trials with both high internal and external validity are now required to establish what type, format, and intensity of brief psychological therapy is required to achieve sustained benefits. Practitioner points Clinical implications: This review provides the first meta-analytical synthesis of brief psychological therapy delivered in acute psychiatric inpatient settings. This review suggests that brief psychological therapy may be associated with reduced emotional distress and readmissions. Limitations The evidence in this review is of limited quality. The type, format, and intensity of brief psychological therapy required to achieve sustained benefits are yet to be established.

Many theoretical urban sanitation planning approaches exist, but there is limited evidence of the successful implementation of these approaches, prompting questions about their suitability, especially in complex urban environments in low-income countries. Using primary and secondary data from Lusaka, Zambia, we explore possible limitations of these theoretical planning approaches in informal peri-urban areas. The findings show that while the “enabling environment” aspects stressed by the literature are weak here, these limiting factors are significantly affected by a poor planning culture and inherent dynamics of power, politics and history. A fuller understanding of the local situation is needed to support the transition of planning approaches from theory to reality, so that real progress in sanitation service delivery can be achieved in complex urban environments.

During the 1980s, John Kalbermatten and his colleagues at the World Bank revolutionised urban sanitation planning. During the last 30 years urban sanitation planning theory has evolved from an engineering focus to a more participatory, multi-disciplinary and user-focused future, informed largely by the work of John Kalbermatten. This paper looks at a number of the most important urban sanitation planning approaches that have emerged post-Kalbermatten and seeks to trace the influence of Kalbermatten's work on their theoretical underpinnings and characteristics. The extent to which other ideas, such as the sanitation value chain, have increasingly been incorporated into planning approaches is discussed and some of the challenges affecting successful urban sanitation which lie outside of planning are considered. Final comments centre on common themes occurring in practice, the future exploration of which offers potential to inform successful sanitation delivery in the future.

This paper simultaneously explores temporal changes in drinking water quality and practices in peri-urban Peru. A mixed methodology approach was used, which included a household survey ( n = 96) and analysis of water samples taken at source ( n = 33 2006, n = 64 2007) and from households ( n = 51 2006, n = 91 2007), during both the dry (2006) and rainy season (2007). Variations in practices were found, the most important being the type of water being used, but these changes were found to be contextual and linked to the termination of municipal piped water to the community, rather than seasonal. Seasonal changes in quality of ground water sources were found, but the change in the quality of the major water sources used for drinking and cooking were again not seasonal. A relationship between drinking water practices and quality was identified, due to household contamination of water, which was linked to perceived quality of source. Although the results from this study do not establish any link between seasonal drinking water quality and practices, evidence supporting the general hypothesis of this work was uncovered.

Objective To analyse the co-construction of self-care advice in traditional acupuncture consultations. Method Analysis of 27 audio-recorded and transcribed consultations, involving 7 practitioners, augmented by integrating the data from 15 patient interviews and regular practitioner discussions. Results Self-care talk was initiated equally by practitioner and patient, and was threaded through and between acupuncture consultations. It involved interactive discussions that were interwoven with other types of talk, especially life-world and acupuncture talk. Practitioner engagement in self-care talk appeared to increase with experience. The self-care talk was co-constructed within the context of a relationship that was characterised by continuity, mutuality and trust. Conclusion Self-care support and advice was integral to the practice of traditional acupuncture and individualised in terms of the patient's life-world and/or the Chinese medicine diagnosis. The co-construction of self-care talk did not replicate the asymmetry of conventional medical consultations. Practice implications The active participation of both patients and acupuncture practitioners in self-care talk may be related to professional practice that is underpinned by a holistic theory base such as Chinese medicine and is delivered in the context of therapeutic relationships based on continuity, mutuality and trust. These findings may inform professional education and the design of multi-disciplinary care pathways.

Globally, access to improved water sources is lower in rural areas compared to urban areas. Furthermore, in rural areas many people use water from individual systems they have developed with their investments, often without external support. This phenomenon has been called Self-supply. Self-supply ranges from simple to complex systems and different water sources. Water quality varies, from achieving the microbial World Health Organization (WHO) standard (0 Colony Forming Units per 100 millilitres -CFU/100 ml) to systems that provide water posing high risks to human health. While most studies in Self-supply have been developed in Africa, little is known in Latin America and the Caribbean (LAC). This research explores Self-supply in a rural microcatchment in Colombia (LAC). This research collected and analysed data from household and drinking water surveys. Results showed that 40% of households used Self-supply systems taking water from springs and brooks. Thermotolerant Coliforms were below 50 CFU/100 ml, during both dry and rainy season, and between 5 to 7% of samples achieved the microbial WHO standard. These results suggest that Self-supply has potential to offer safe drinking water, provided improvements on source protection and institutional support. Therefore, Self-supply could contribute to address "unfinished business", including ensuring access for the hardest-to-reach people, as stated in the United Nations post-2015 development agenda.

Background People with medically unexplained physical symptoms (MUPS) are helped by interventions that combine physical and psychological explanations and treatment. Traditional acupuncture may offer such a perspective, but its use for these patients has not been investigated. Aim To ascertain how patients with MUPS perceive and experience five-element acupuncture treatment. Design and setting A longitudinal qualitative interview study, nested in a randomised controlled trial was carried out in four general practices in socioeconomically diverse areas of London. Method A purposive sample of 20 trial participants was interviewed twice, at the start and the end of 6 months of acupuncture treatment. Semi-structured interviews were transcribed, coded, and analysed thematically, summarising both across-case as themes and within-case individual vignettes. Results Acupuncture, initially accepted as ‘just another referral’ — one like many others that had been tried and proved unsuccessful — was valued for the amount of time allotted with a caring practitioner who listened and responded, as well as for the interactive and holistic nature of the sessions. These attributes encouraged many patients to take an active role in their treatment, including making cognitive or behavioural lifestyle changes. Interviewees cited a wide range of changes in their health that spanned physical, psychological, and social dimensions. These were largely positive and included an increase in physical and/or mental energy, as well as feelings of greater personal control, calmness, and relaxation. Three interviewees reported worsening health but did not ascribe this to acupuncture. Conclusion Many patients who were treated with five-element acupuncture perceived a range of positive effects and appeared to take on a more active role in consultations and self-care.

A set of outcome questionnaires has been developed to measure the range of treatment effects of traditional acupuncture. In this descriptive outcome study we validated these questionnaires in a busy National Health Service funded acupuncture clinic serving communities of diverse socio-economic circumstances. Some of the questionnaires performed better than others in this setting but EQ-5D and MYMOP-qual both showed statistically and clinically significant improvement in physical and psychological health after six weeks and six months, in all categories of disease and degrees of chronicity. Both the written qualitative data and the Patient Enablement Instrument (PEI) demonstrated considerable patient enablement and, for some patients, the acquisition of new coping and self-care strategies.The questionnaires were feasible to administer, acceptable to patients and clinic staff, and provided robust and detailed quantitative and qualitative outcome data of use for service provision, future planning, and as a basis for further cost-effectiveness studies.

Objectives: To characterize the diverse nature of peoples' experiences of acupuncture treatment for chronic health problems. Specifically, the paper addresses how this analysis deepens our understanding of holism and its relation to the therapeutic theory base. Methods: A secondary analysis of five longitudinal interview studies using a constant comparative method. Patients experienced different types of acupuncture — traditional (based on Chinese medicine) and Western-style (based on biomedicine) in a variety of settings in the UK and Australia. Results: The markedly different experiences of acupuncture treatment were best characterized in relation to the concept of holism. Being treated `as a whole person' was associated with traditional acupuncture in both private and NHS practice, but not within a research trial setting. In the trial, both patients and practitioners `played their part' in a scientific experiment. Holism was especially important to people with several health problems. Discussion: The findings suggests that the experience of holistic care, in the sense of `being treated as a whole person' is dependent on four factors: (a) the therapeutic theory that underpins the treatment; (b) structural factors such as time and setting; (c) the intention of the practitioner; and (d) the intention and needs of the patient.

Summary Objective To describe a massage therapy and training programme in a remote Aboriginal community in Australia and to develop the frameworks, procedures and processes necessary for future research. Method Self-report health questionnaires (MYMOP and W-BQ12) and an ethnographic enquiry that included participant observation and 15 interviews with clients and key informants. Results The project was disrupted by typhoons. Baseline questionnaire responses indicate they may be suitable for this context. Qualitative analysis resulted in a conceptual model of the effects of the programme, which is consistent with a system theory approach. People's accounts were rooted in discussions of the community's history, emotional and physical distress, and limited health care resources. Community-level effects included increasing participation; strengthening local health and educational projects; and opening up new opportunities. Individual level effects included improvement in physical and emotional symptoms, improved function and the receipt of preventative care. Conclusion As a result of this early stage research, future studies have a conceptual model to guide them and evidence that a mixed method and a participatory methodology may be the most appropriate design.

Qualitative research has an important part to play in investigating how complex interventions are implemented within randomized controlled trials (RCTs) and what impact the RCT context has on participants, their behavior, and their outcomes. We explored these issues within a randomized sham-acupuncture controlled trial of traditional Chinese acupuncture for people with migraine.All trial participants who consented to take part in this qualitative study were interviewed twice by a researcher who was blind to all trial data. The acupuncture practitioner was interviewed once. Nineteen (19) semistructured interviews, 30-60 minutes long, were transcribed, coded, and analyzed both across and within cases.The 10 participants, 6 female, age 23-70 years had severe migraine and conventional treatment had been of limited benefit. They were satisfied with the organization of the trial and no acupuncture was perceived as obviously "sham." Most participants, and the practitioner, actively "played their part" in the trial, taking on research roles that differed from their usual roles of "patient" and "doctor." The resulting changes to their normal expectations and behavior influenced how the intervention was delivered and experienced. There was a reduction in talking, explanations, and participation, and treatment was focused on the migraine and usually excluded other conditions, even if the participants considered them to be a cause or a trigger of the migraine.We conclude that treatment in the trial differed from that described in studies of "real life" traditional acupuncture. These differences affected the needling-the characteristic or specific intervention-as well as contextual factors. This trial design limitation appears to be inevitable when a sham-controlled design is used to research an intervention that is based on a holistic and participative treatment strategy. These findings should be taken into account in the design and interpretation of RCTs of complex interventions such as acupuncture.

It is estimated that at least two billion people have inadequate sanitation. The current situation in water and sanitation services for millions of peri-urban residents is starkly anti-poor and represents a major challenge for the 21st century. By virtue of its cost and water requirements, we would argue that conventional sewerage is an implicitly anti-poor technology. This paper summarises low-cost sanitation technologies that have been developed by engineers from around the world, and seeks to provide evidence that there is such a thing as a pro-poor technology. We argue that simplified sewerage is often the only sanitation technology that is technically feasible and economically appropriate for low income, high-density urban areas. Simplified sewerage will only truly be a pro-poor technology if issues such as lack of investment in sanitation, insufficient cost recovery for sanitation services, conservative technical standards favoured over innovation, low-cost technologies perceived as second class provision, the nature of peri-urban settlements, and lack of engagement with users, are addressed. So often, peri-urban sanitation schemes fail to exist, fail to be sustainable, or fail to be pro-poor. The challenge is for engineers, social scientists and other professionals to work together to make pro-poor sanitation a reality and interdisciplinarity the norm.

The goal of this study is the determination of key themes to aid the analysis of qualitative data collected at three cancer support centres in England, using the Measure Yourself Concerns and Wellbeing (MYCaW) questionnaire. People with cancer who use complementary therapies experience and value a wide range of treatment effects, yet tools are urgently required to quantitatively measure these outcomes. MYCaW is an individualised questionnaire used in cancer support centres providing complementary therapies, scoring ‘concerns or problems’ and ‘well-being’ and collecting qualitative data about other major events in a patient’s life and what has been most important to the patient. Content analysis on 782 MYCaW questionnaires from people at these cancer support centres was carried out. The ‘concerns,’ ‘other things going on in their life’ and ‘important aspects of centre’ were thematically categorised and externally validated by a focus group, and the inter-rater reliability was calculated. Clinical information from a cancer patient’s perspective was collected that is not measured on standard quality-of-life questionnaires; furthermore, some themes acknowledge the multi-faceted aspects of complementary and alternative medicine provision, rather than information only relating to the therapeutic intervention. Categories for qualitative MYCaW analysis have been established providing a tool for future research and/or service delivery improvement within cancer support centres such as these. The established themes provide a framework to aid analysis of qualitative aspects of complementary therapy care for people with cancer, improving our understanding of how the patient’s cancer experience can be aided by complementary therapies in specialised cancer centres.

Objectives To investigate patients’ perspectives of the process and outcome of Western-style acupuncture for chronic health problems. To use these results to inform the provision of acupuncture in health services in the UK. Methods A purposive sample of 18 patients who were having Western-style acupuncture, for the first time, for a health problem of at least three months duration, were interviewed twice over a four-month period using semi-structured interviews. Using a constant comparative method, the data were analysed across cases and within cases. Results The interviewees complained of chronic pain and moderate or severe disability which was resistant to conventional treatment. Their experience of acupuncture was diverse and varied according to the ‘dosage’ of acupuncture received, the inclusion of self-care strategies, and their relationship with the practitioner. These three factors were interlinked and constituted individual styles of practice for each practitioner. The majority of patients benefited in terms of complete or partial relief of pain and disability, and reduction in conventional medication. However, some patients were disappointed by the treatment, distressed about ‘wasting people's time’, and about the lack of continuity of care. People who benefited most had good general health and a single problem. Conclusions Patients showed discerning judgement regarding the ‘dosage’ of acupuncture they required, and combined acupuncture with exercises to good effect. Publicly funded health services should provide an acupuncture service that provides the optimal ‘dosage’ and uses pain relief to promote self-care. Further research to investigate the benefits of a service that combines Western-style and traditional acupuncture is planned.

Opioids are increasingly prescribed for chronic noncancer pain across the developed world. Clinical guidelines for management of these patients focus on over-use. However, research into other types of long-term medication indicates that many patients minimize drug use whenever possible.To identify the varying influences on patients' decisions about their use of prescribed opioids and explore whether concepts of resistance and minimization of intake apply to these patients.A multiprofessional team performed a qualitative interview study using the constant-comparative method. Patient's decision making was explored in depth and with a thematic analysis utilizing a published "Model of medicine-taking."A purposive sample of 20 participants drawn from two pain clinics in Melbourne, Australia. The sample was biased toward patients interested in nonmedication pain management options.Patients' needs to obtain relief from severe pain, maintain function, and minimize side effects could lead to under-use as well as over-use of prescribed opioids. In keeping with the published Model of medicine-taking, resistance to taking opioids was a common and important influence on behavior. In the face of severe chronic pain, many participants used a variety of strategies to evaluate, avoid, reduce, self-regulate, and replace opioids. Furthermore, participants perceived a resistance to opioids within the system and among some healthcare professionals. This sometimes adversely affected their adherence.Both patients and doctors exhibit aspects of resistance to the use of prescribed opioids for chronic noncancer pain, suggesting that this shared concern could be the basis of a productive therapeutic alliance to improve communication and shared decision making.Clinical guidelines for opioids use for chronic noncancer pain focus on over-use. Our qualitative interview study found that many patients resisted and minimized the use of opioids. Using a published "Model of medicine-taking," we identified various influences on patient decision making. Both patients and doctors had concerns about using opioids for chronic noncancer pain. These could be the basis of a productive therapeutic alliance to improve communication and shared decision making.

Background. Opioids are increasingly prescribed for chronic noncancer pain across the developed world. Clinical guidelines for management of these patients focus on over-use. However, research into other types of long-term medication indicates that many patients minimize drug use whenever possible. Objective. To identify the varying influences on patients’ decisions about their use of prescribed opioids and explore whether concepts of resistance and minimization of intake apply to these patients. Design. A multiprofessional team performed a qualitative interview study using the constant comparative method. Patient’s decision making was explored in depth and with a thematic analysis utilizing a published “Model of medicine-taking.” Setting and participants. A purposive sample of 20 participants drawn from two pain clinics in Melbourne, Australia. The sample was biased toward patients interested in nonmedication pain management options. Findings. Patients’ needs to obtain relief from severe pain, maintain function, and minimize side effects could lead to under-use as well as over-use of prescribed opioids. In keeping with the published Model of medicine-taking, resistance to taking opioids was a common and important influence on behavior. In the face of severe chronic pain, many participants used a variety of strategies to evaluate, avoid, reduce, self-regulate, and replace opioids. Furthermore, participants perceived a resistance to opioids within the system and among some healthcare professionals. This sometimes adversely affected their adherence. Conclusions. Both patients and doctors exhibit aspects of resistance to the use of prescribed opioids for chronic noncancer pain, suggesting that this shared concern could be the basis of a productive therapeutic alliance to improve communication and shared decision making. Summary. Clinical guidelines for opioids use for chronic noncancer pain focus on over-use. Our qualitative interview study found that many patients resisted and minimized the use of opioids. Using a published “Model of medicine-taking,” we identified various influences on patient decision making. Both patients and doctors had concerns about using opioids for chronic noncancer pain. These could be the basis of a productive therapeutic alliance to improve communication and shared decision making.

Prostate cancer is the second most common cancer in men worldwide, accounting for an estimated 1.1 million new cases diagnosed in 2012 (www.globocan.iarc.fr). Currently, there is a lack of specific guidance on supportive care for men with prostate cancer. This article describes a qualitative systematic review and synthesis examining men's experience of and need for supportive care. Seven databases were searched; 20 journal articles were identified and critically appraised. A thematic synthesis was conducted in which descriptive themes were drawn out of the data. These were peer support, support from partner, online support, cancer specialist nurse support, self-care, communication with health professionals, unmet needs (emotional support, information needs, support for treatment-induced side effects of incontinence and erectile dysfunction) and men's suggestions for improved delivery of supportive care. This was followed by the development of overarching analytic themes which were: uncertainty, reframing, and the timing of receiving treatment, information and support. Our results show that the most valued form of support men experienced following diagnosis was one-to-one peer support and support from partners. This review highlights the need for improved access to cancer specialist nurses throughout the care pathway, individually tailored supportive care and psychosexual support for treatment side effects.

Summary Objective To carry out a pilot study, with particular attention to adequacy of outcome measures. Design Observational study and user participation. Setting and participants A local user group selected seven participants with a wide range of illness severity. Intervention A course of eight 1 hr sessions of deep whole body (therapeutic) massage over 8 weeks. Outcome measures The Parkinson's Disease Questionnaire (PDQ-39), the Measure Yourself Medical Outcome Profile (MYMOP), and the Medication Change Questionnaire (MCQ). Semi-structured interviews, before and after the intervention. Results In addition to enjoying the massage, individuals showed improvement in self-confidence, well-being, walking and activities of daily living. There was good agreement between data from the outcome questionnaires, interviews and clinical notes. User involvement highlighted issues that would otherwise have been ignored. Conclusions The study confirms the benefits of involving users in the research process and makes recommendations concerning the design of any future randomised trial.

Our understanding of acupuncture and Chinese medicine is limited by a lack of inquiry into the dynamics of the process. We used a longitudinal research design to investigate how the experience, and the effects, of a course of acupuncture evolved over time.This was a longitudinal qualitative study, using a constant comparative method, informed by grounded theory. Each person was interviewed three times over 6 months. Semistructured interviews explored people's experiences of illness and treatment. Across-case and within-case analysis resulted in themes and individual vignettes.Eight (8) professional acupuncturists in seven different settings informed their patients about the study. We interviewed a consecutive sample of 23 people with chronic illness, who were having acupuncture for the first time.People described their experience of acupuncture in terms of the acupuncturist's diagnostic and needling skills; the therapeutic relationship; and a new understanding of the body and self as a whole being. All three of these components were imbued with holistic ideology. Treatment effects were perceived as changes in symptoms, changes in energy, and changes in personal and social identity. The vignettes showed the complexity and the individuality of the experience of acupuncture treatment. The process and outcome components were distinct but not divisible, because they were linked by complex connections. The paper depicts these results as a diagrammatic model that illustrates the components and their interconnections and the cyclical reinforcement, both positive and negative, that can occur over time.The holistic model of acupuncture treatment, in which "the whole being greater than the sum of the parts," has implications for service provision and for research trial design. Research trials that evaluate the needling technique, isolated from other aspects of process, will interfere with treatment outcomes. The model requires testing in different service and research settings.

Summary Objective: People who seek non-pharmaceutical interventions are often motivated by a desire to avoid or reduce orthodox medication. Effectiveness research in these areas needs to measure change in medication as an outcome. We set out to develop a data collection tool that is sensitive to changes in individual drug use over time. Method: A multi-disciplinary team designed, piloted, and revised the Medication Change Questionnaire (MCQ) on two occasions, and used qualitative interviews to understand the patient's perspective and ensure that the final product accurately reflected the medication that patients were taking. Thirty patients in one general practice completed the questionnaire on two occasions and a purposive sample of 14 were interviewed. The design sought to enable patients to record all their ingested medication accurately, both prescription and over-the-counter drugs, over a period of 7 days. It was designed to be administered face-to face on the first occasion, and to be self-completed on subsequent occasions. Results: In considering in detail what medication was taken each day, the interview data fully correlated with the MCQ data in only one of the five people who were interviewed after completing the first draft of the questionnaire, but in eight of the nine people who completed the second draft. Of these eight people all but one had made some change to their medication, either by stopping or starting a drug, varying the dose of a drug or always taking one or more drugs in varying doses. The interviews demonstrated the complex and individual ways that people took their medicines, and the disparity between what was prescribed and what was actually taken. The qualitative data were also useful for reflecting on the potential advantages and disadvantages of other data collection methods, such as single medication questions and pill counts. Conclusion: By involving patients at every level of research, we have developed a questionnaire that enables people to record their medication use accurately over a 7-day period, and to demonstrate changes in medication over time. Further work is required to assess its acceptability by different patient populations and its feasibility in terms of completion rates over longer periods of repeated use. We believe the MCQ to be an improvement over the variety of ad-hoc tools used in the past and it is freely available from the authors.

Objectives: For people with dyspepsia who are receiving orthodox general practice care, what is the effect on outcome and on NHS costs of adding treatment by a choice of acupuncture or homeopathy? This paper describes and reflects upon a pilot study with user involvement. Design: A randomised pilot study. Patients chose between acupuncture and homeopathy and were then randomised to this preference or to the control group of normal GP care. Setting and participants: Sixty people with dyspepsia (≥2 weeks) presenting in one UK general practice were recruited in consultations and by letter to those on repeat prescriptions. There were few exclusion criteria. The homeopath and the acupuncturist treated the patient individually according to their normal practice for up to 6 months. After the trial there was a focus group for participants. Outcome measures: SF-36 health survey, Measure Yourself Medical Outcome Profile (MYMOP), and General Well-being Index (GWBI). Counts of prescriptions, consultations and referrals from practice computer records. Results: No trend or significant difference between the groups for clinical outcome or NHS costs. Major costs for the 6 months, mean (S.D.) cost per patient, were general practitioner consultations £8 (18), prescriptions £64 (73), acupuncture £175 (52), homeopathy £105 (33). Participants gave insights and suggestions which will inform the full trial design. Conclusions: Reflection on the pilot study data and experience by participants, treating practitioners and researchers led to modifications in the design and a sample size calculation. How to demonstrate individual responses to treatment remains a problem.

There is little published information on the measurement of health status or quality of life in acute exacerbations of chronic bronchitis. The measure yourself medical outcome profile (MYMOP), the medical outcomes study 6-item general health survey (MOS-6A), and EuroQoL (EQ-5D) were evaluated in 81 patients with acute exacerbations of Type-1 chronic bronchitis presenting at a single general practice centre in Glasgow. The questionnaires were administered at the first clinic visit and at a second visit within 1 week of treatment completion. Item scores for MYMOP were generally more responsive than those for the other instruments, as assessed by standardised response means and an index of responsiveness for those patients reporting minimal change between visits. Construct validity was demonstrated for the MYMOP by the gradient in score change with the patient's perceived change in clinical condition and by the relationship between score change and the physician's assessment of clinical outcome. This study demonstrated that the MYMOP is a valid and potentially useful instrument for the assessment of patient outcomes in acute exacerbations of chronic bronchitis and is more responsive than the MOS-6A or EQ-5D in this setting. The choice of instrument will vary according to the objective of the study.

To investigate the progression of the illness and opioid journeys of people who are taking opioids for chronic non-cancer pain. Methods. In-depth qualitative interviews were conducted with 20 people who were taking opioids for non-cancer pain. A purposive sample was drawn from patients attending two pain clinics in Melbourne, Australia. Transcripts were analyzed within case, as individual narratives, and across case, as a thematic analysis. Conceptual explanatory variables were developed. Results. The experience of taking opioids for chronic non-cancer pain varies greatly between individuals and these diverse narratives-chaos, restitution, and quest narratives-raise questions about why and how some individuals find a way forward, while others remain in situations of chaotic and worsening ill health. We offer an explanation for this variability in terms of four key influences: support from individual health professionals and the health system; medical explanation or solutions; social support and social responsibilities; and the use of non-pharmaceutical interventions and self-help strategies. A unifying theme was the importance of maintaining hope. Conclusion. The four key factors influencing the progress of people taking opioids for chronic noncancer pain are rooted in the provisions made by society for caring for this patient group and involve relationships between patient and provider, between patients and their social world, and between different providers and their professional knowledge. In our patient sample, effective support involved the provision and maintenance of hope, and professionals who are knowledgeable about opioids and chronic pain, good communicators, and cognizant with their patients' social support and responsibilities.

Background Improving the health of Indigenous Australians remains a major challenge. A chiropractic service was established to evaluate this treatment option for musculoskeletal illness in rural Indigenous communities, based on the philosophy of keeping the community involved in all the phases of development, implementation, and evaluation. The development and integration of this service has experienced many difficulties with referrals, funding and building sustainability. Evaluation of the program was a key aspect of its implementation, requiring an appropriate process to identify specific problems and formulate solutions to improve the service. Methods We used the normalisation process model (May 2006) to order the data collected in consultation meetings and to inform our strategy and actions. The normalisation process model provided us with a structure for organising consultation meeting data and helped prioritise tasks. Our data was analysed as it applied to each dimension of the model, noting aspects that the model did not encompass. During this process we reworded the dimensions into more everyday terminology. The final analysis focused on to what extent the model helped us to prioritise and systematise our tasks and plans. Results We used the model to consider ways to promote the chiropractic service, to enhance relationships and interactions between clinicians and procedures within the health service, and to avoid disruption of the existing service. We identified ways in which chiropractors can become trusted team members who have acceptable and recognised knowledge and skills. We also developed strategies that should result in chiropractic practitioners finding a place within a complex occupational web, by being seen as similar to well-known occupations such as physiotherapy. Interestingly, one dimension identified by our data, which we have labelled ‘emancipatory’, was absent from the model. Conclusions The normalisation process model has resulted in a number of new insights and questions. We have now established thriving weekly chiropractic clinics staffed by a team of volunteer chiropractors. We identified an ‘emancipatory’ dimension that requires further study. We provide a worked example of using this model to establish, integrate and evaluate a chiropractic service in an Indigenous Australian community.

BACKGROUND Promotion of self-care for persistent back pain and other long-term conditions has become a central component in health care policy in the UK, and general practitioners face increasing demands to support patients' self-care efforts. Gaining insight into patients' views may facilitate support. OBJECTIVE To describe patients' experience of self-care for long-term back pain and their views on provision of support for self-care. METHODS Adults experiencing persistent back pain were purposively sampled from a community-based survey. In-depth qualitative interviews were audiotaped, transcribed and analysed using the constant comparative method to inductively derive a thematic account of the data. RESULTS Most of the 23 interviewees felt a responsibility to self-care. Individual capacity for self-care, however, was variable and could be inhibited by factors such as caring roles or lack of diagnosis and information. GP support for self-care was largely considered to be desirable, although the feasibility of greater provision of support was questioned. Some interviewees expressed a strong preference for alternative models of care and support. CONCLUSION Self-care for back pain is contextualized by the individual's capacity to self-care and preferences for support. Doubt over the ability of GPs to provide support for self-care may mean that those who have specific needs are reticent to seek help. The role of self-care in the management of back pain should be discussed openly at the consultation level, and GPs may be well placed to signpost patients and provide guidance on the safety of specific self-care activities.

Background Group acupuncture clinics have been introduced in a London hospital and in two general practices in Hertfordshire for the treatment of knee osteoarthritis (OA). Encouraging preliminary reports have been published of the efficacy of the treatment delivered in this setting but its acceptability to patients has not yet been established. The aim was to investigate the acceptability and perceived advantages and disadvantages of acupuncture delivered in the group setting for the treatment of knee OA. Methods Semistructured interviews were conducted with 16 patients in their own homes and with four nurses over the telephone. Interviews were recorded, transcribed, fully anonymised and analysed thematically. Results Group acupuncture was delivered with enthusiasm by nurses, was acceptable and popular with patients and recognised to be cost-efficient. Factors affecting acceptability were situational, interpersonal and intrapersonal. Situational factors included adequacy of the physical space used, flexibility of the appointment system and the changing and adaptable nature of the group. Interpersonal factors were mutual support, the exchange of information, the provision of mixed or single-sex sessions and the role of the acupuncture nurse. Intrapersonal factors that increased acceptability were less clear, but nurses expressed the view that the group setting was less suitable for patients with complex conditions or severe pain. Conclusions Acceptability is very high and may be maximised by taking a number of factors into account: full information should be provided before treatment begins; flexibility should be maintained in the appointment system and different levels of contact between fellow patients should be fostered; sufficient space and staffing should be provided and single-sex groups used wherever possible.

Background The Danish Multiple Sclerosis Society initiated a large-scale bridge building and integrative treatment project to take place from 2004–2010 at a specialized Multiple Sclerosis (MS) hospital. In this project, a team of five conventional health care practitioners and five alternative practitioners was set up to work together in developing and offering individualized treatments to 200 people with MS. The purpose of this paper is to present results from the six year treatment collaboration process regarding the development of an integrative treatment model. Discussion The collaborative work towards an integrative treatment model for people with MS, involved six steps: 1) Working with an initial model 2) Unfolding the different treatment philosophies 3) Discussing the elements of the Intervention-Mechanism-Context-Outcome-scheme (the IMCO-scheme) 4) Phrasing the common assumptions for an integrative MS program theory 5) Developing the integrative MS program theory 6) Building the integrative MS treatment model. The model includes important elements of the different treatment philosophies represented in the team and thereby describes a common understanding of the complexity of the courses of treatment. Summary An integrative team of practitioners has developed an integrative model for combined treatments of People with Multiple Sclerosis. The model unites different treatment philosophies and focuses on process-oriented factors and the strengthening of the patients’ resources and competences on a physical, an emotional and a cognitive level.

Medically unexplained physical symptoms (MUPS) are common and difficult to treat.To investigate the effectiveness of adding five-element acupuncture to usual care in 'frequent attenders' with MUPS.Randomised controlled trial in four London general practices.Participants were 80 adults with MUPS, consulting GPs ≥8 times/year. The intervention was individualised five-element acupuncture, ≥12 sessions, immediately (acupuncture group) and after 26 weeks (control group). The primary outcome was 26-week Measure Yourself Medical Outcome Profile (MYMOP); secondary outcomes were wellbeing (W-BQ12), EQ-5D, and GP consultation rate. Intention-to-treat analysis was used, adjusting for baseline outcomes.Participants (80% female, mean age 50 years, mixed ethnicity) had high health-resource use. Problems were 59% musculoskeletal; 65%1 year duration. The 26-week questionnaire response rate was 89%. Compared to baseline, the mean 26-week MYMOP improved by 1.0 (95% confidence interval [CI] = 0.4 to 1.5) in the acupuncture group and 0.6 (95% CI = 0.3 to 0.9) in the control group (adjusted mean difference: acupuncture versus control -0.6 [95% CI = -1.1 to 0] P = 0.05). Other between-group adjusted mean differences were: W-BQ12 4.4 (95% CI = 1.6 to 7.2) P = 0.002; EQ-5D index 0.03 (95% CI = -0.11 to 0.16) P = 0.70; consultation rate ratio 0.90 (95% CI = 0.70 to 1.15) P = 0.4; and number of medications 0.56 (95% CI = 0.47 to 1.6) P = 0.28. All differences favoured the acupuncture group. Imputation for missing values reduced the MYMOP adjusted mean difference to -0.4 (95% CI = -0.9 to 0.1) P = 0.12. Improvements in MYMOP and W-BQ12 were maintained at 52 weeks.The addition of 12 sessions of five-element acupuncture to usual care resulted in improved health status and wellbeing that was sustained for 12 months.

The study objective was to develop methodology for observational research within traditional acupuncture consultations in community-based practice, and to explore how traditional acupuncturists communicate with patients about lifestyle and self-care.This was a mixed-method qualitative study, using audio-recording of consultations followed by telephone interviews of patients. The study was nested within a cooperative inquiry. As co-researchers, group members participated in framing the research questions, deciding methods to be used, and discussing the emergent findings.Four (4) experienced traditional acupuncture practitioners, registered with the British Acupuncture Council, contributed to the co-operative enquiry and recorded consultations in three clinics in Somerset.Subjects comprised a convenience sample of patients attending 21 consultations. A purposive subsample of patients was selected for interview.Audio-recording was challenging to some practitioners who felt that it might result in infrequent, but nevertheless worrying, withholding of personal information by patients. Patients, however, reported that they were generally positive about the audio-recording. Each consultation was analyzed as a trajectory in which eight categories of talk interwove with each other and with periods of physical examination, needling, and silence. Trajectories showed where talk about self-care ("self-care talk") appeared in the consultations, the content of such talk, and who initiated it. The data confirmed that self-care advice arises from, and is explained in terms of, each person's individual Chinese Medicine diagnosis. The identification of different types of talk and the way that "self-care talk" is interwoven throughout the consultation emphasized the integral nature of self-care support and advice in the practice of traditional acupuncture. Some patients had difficulty putting self-care advice into practice, even when they were intellectually committed to it, suggesting that practitioners may need to follow up more carefully on the advice they have given.Self-care in traditional acupuncture consultations is integral, interactive, and individualized. This study has mapped out a potential agenda for research into self-care in traditional acupuncture consultations and illustrates the exciting opportunities that open up when observational and interview data are combined.

Background Self-care is a key component of current policies to manage long term conditions. Although most people with long-term health problems care for themselves within lay networks, consultation rates for long-term undifferentiated illness remain high. Promotion of self-care in these individuals requires an understanding of their own self-care practices and needs to be understood in the context of health care pluralism. The aim was to investigate the extent and nature of self-care practices in patients experiencing long term health problems, sources of information used for self-care, and use of other forms of health care (conventional health care and complementary and alternative medicine). Methods The study involved a cross-sectional community-based survey set in three general practices in South West England: two in urban areas, one in a rural area. Data were collected using a postal questionnaire sent to a random sample of 3,060 registered adult patients. Respondents were asked to indicate which of six long term health problems they were experiencing, and to complete the questionnaire in reference to a single (most bothersome) problem only. Results Of the 1,347 (45% unadjusted response rate) who responded, 583 reported having one or more of the six long term health problems and 572 completed the survey questionnaire. Use of self-care was notably more prevalent than other forms of health care. Nearly all respondents reported using self-care (mean of four self-care practices each). Predictors of high self-care reported in regression analysis included the reported number of health problems, bothersomeness of the health problem and having received a diagnosis. Although GPs were the most frequently used and trusted source of information, their advice was not associated with greater use of self-care. Conclusions This study reveals both the high level and wide range of self-care practices undertaken by this population. It also highlights the importance of GPs as a source of trusted information and advice. Our findings suggest that in order to increase self-care without increasing consultation rates, GPs and other health care providers may need more resources to help them to endorse appropriate self-care practices and signpost patients to trusted sources of self-care support.

This article describes a qualitative synthesis of published research on cancer patients’ experiences of complementary therapies. We conducted a systematic search for qualitative studies on this subject published between 1998 and 2007. Twenty-six refereed journal articles met the inclusion criteria. These 26 articles were repeatedly read by the research team and key concepts emerging from them were identified. Differences and variations were examined in association with treatment, therapy type and by stage of cancer (early stage, mid-treatment, advanced cancer, palliative care and long term ‘survivors’). Six overarching concepts were located, which describe the key aspects of patients’ experiences of the use of complementary and alternative medicine after a diagnosis of cancer: Connection; Control; Well-being; Transformation; Integration; and Polarization. These are described in a ‘line of argument’ synthesis, and differences associated with treatment type and stage of disease are noted. The findings are presented in a table showing the six concepts according to treatment type and stage; as a composite story; and in a diagrammatic model showing the individual, practitioner and organizational levels. The synthesis identified various specific ways in which complementary therapies supported cancer patients, as well as occasional negative effects. The most notable barrier was the perceived polarization of complementary therapies and biomedicine; patients reported better experiences in integrated settings.

Summary Background Many patients with musculoskeletal pain prefer topical treatments because they consider them safer than oral drugs. There is a long history of topical use of nettle sting for pain, but no standard method of application. Our objective was to develop a consensus of the experiences of nettle sting users. Methods A consensus study was conducted using the expert panel method. Media articles resulted in 16 responses and nine users attended a meeting. Participants first responded to questions on how they chose the leaf and how they applied the nettle sting; then discussed their individual responses; and finally responded once more to the same questions. Consensus was defined as 70% agreement. Participants' consensus was developed from the responses and discussions, and modified in response to repeated feedback and to comments of seven other nettle users. Results Consensus was present initially on three questions: ‘ Important to feel a good strong sting ', ‘ Immediately sting the area again ' and ‘ Sting once a day '. Opinions on the method and site of application, and format of a course of treatment varied. This range of advice was incorporated into a treatment consensus document acceptable to all users in the study. Conclusions The users' consensus document for the use of nettle sting for musculoskeletal pain is published for anyone who wishes to use this self-care approach to treating their pain. The user's consensus document represents an essential step in undertaking further research into the effectiveness of nettle sting as a treatment for musculoskeletal pain.

Objective The use of complementary therapies by people with cancer is commonplace. In a recent synthesis of 26 qualitative studies of patients' experiences of complementary therapy use after a diagnosis of cancer, the emergent theme of ‘polarization’ was the most notable barrier to a positive experience of complementary therapies. In this paper, we explore the two synthesis concepts of ‘polarization’ and ‘integration’, and their relationship to health service policies and guidelines on integrated services. Methods A systematic literature search and a meta-ethnography to synthesize key concepts. Results The majority of patients who used complementary therapies after a diagnosis of cancer wanted to be certain that the therapies were not interfering with their conventional cancer treatment. They valued the therapies in wider terms including: taking ‘a niche of control’, relieving symptoms, improving wellbeing, and promoting reconnection and social interaction. The emergent theme of ‘polarization’ suggested that conventional physicians who are perceived to be poorly informed or negative about complementary approaches induce patient anxiety, safety concerns, and difficulties in access. They may compromise their therapeutic relationship and, rarely, they may trigger patients to abandon conventional medicine altogether. In contrast, integrated advice and/or services were highly valued by patients, although some patients preferred their complementary health care to be provided in a non-medicalized environment. Conclusions Our findings suggest that the current polarized situation is unhelpful to patients, detrimental to therapeutic relationships and may occasionally be dangerous. They indicate that complementary therapies, in a supportive role, should be integrated into mainstream cancer care.

The editorial on ‘Quality of life: what does it mean for general practice?’1 suggests that including patient-reported quality of life in chronic disease management may help health professionals to understand more about the patient's perspective. In relation to the important question of how best to measure changes in quality of life for patients …